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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200813
Report Date: 06/24/2022
Date Signed: 06/24/2022 02:20:09 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/28/2022 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20220328123115
FACILITY NAME:GABRIEL'S HOUSE 1FACILITY NUMBER:
079200813
ADMINISTRATOR:BERNARDINO, JANE PABUSTANFACILITY TYPE:
740
ADDRESS:3109 CONCORD BLVDTELEPHONE:
(925) 470-7160
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY:6CENSUS: 4DATE:
06/24/2022
UNANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Jane Bernardino, LicenseeTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are intimidating resident
INVESTIGATION FINDINGS:
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On 06/24/22, Licensing Program Analysts (LPA) J Clancy-Czuleger conducted an unannounced subsequent visit and met with Licensee Jane Bernardino, to deliver the findings of above allegation. LPA explained the purpose of the visit with Licensee.

Investigation Finding: UNSUBSTANTIATED

During the course of the investigation, LPA Jill Clancy-Czuleger interviewed Administrator, four residents, and two staff. In the interviews staff stated that they talk to each other in Tagalog. Interviews with other residents and their families state that the staff don’t always speak English, but they have not seen the staff laughing at the residents.

Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20220328123115
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GABRIEL'S HOUSE 1
FACILITY NUMBER: 079200813
VISIT DATE: 06/24/2022
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated. Exit Interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2